Kidneys produce urine continually as a result of filtration of the blood. Urine produced in the kidneys are carried to the urinary bladder via the ducts called ureter. Urine amount varies being related to healthy function of the kidneys and amount of the fluid intake. Urinary bladder is formed of muscular layer and its function is to deposit urine. As it is filled with urine, urinary bladder expands like a balloon. While urinary bladder is resting , muscle layer should be loose and urinary bladder outlet should be off. Urinary bladder outlet is supported with urethral valve (the duct that the urinary bladder opens out) and muscles in the floor of pelvis. When urinary bladder is filled with a certain volume of urine, the person gets the feeling of urination, while the muscle layer of the bladder contracts, urethral valve and pelvic floor muscles relax and urine discharge occurs. In order for a healthy storage and discharge of the urine, the brain should operate with coordination for the stimulation of the urinary bladder and pelvic floor muscle nerves.
Urinary incontinence is defined as involuntary leakage of urine, enuresis or loss of control of the urinary bladder and it is frequent health problem in the public. It’s more frequent in women. Its severity varies , it may develop as dribbling urinary incontinence (stress incontinence) related to coughing, laughing or increased intra-abdominal pressure or as inability to reach the toilet with a sudden feeling of urination (urge incontinence). Sometimes, both types of urinary incontinence may be combined (mixed type incontinence).
If the severity of the urinary incontinence affects daily life and quality of life, physician should be contacted. In many patients, significant results can be achieved with simple changes in life style and simple medical treatments.
Complaints:
Urinary incontinence is involuntary losing control of urinary bladder and may be not only occur in very mild forms but also in severe forms affecting the daily life.
Types of urinary incontinence:
Stress Incontinence: This type of urinary incontinence is defined as dribbling or more amount of urinary incontinence related to coughing, sneezing, laughing or increased intra-abdominal pressure like heavy lifting . Stress incontinence is the result of insufficiency or weakness of the valves in urinary bladder and urethra. Most significant risk factors are pregnancy, delivery and menopause
Urge Incontinence: It is defined as urinary incontinence with a sudden feeling of urination . It develops as a result of involuntary contraction and the person urinates before reaching to the toilet. This kind of difficulty causes frequent urination even at nights. Urinary tract infections, agents causing urinary bladder irritation (calculus, …etc in urinary bladder), intestinal problems, Parkinson disease, Alzheimer disease, diseases such as stroke and multiple sclerosis may be defined as the reasons for urge incontinence. Urge incontinence is also called as hyperactive urinary bladder syndrome in the absence of a disease which causes it.
Overflow Incontinence
Feeling of urination doesn’t occur due to loss of sense despite the fact that the urinary bladder is filled and overflow incontinence occurs when urine is stored with an exceeding limit of urinary bladder capacity in this kind of incontinence which present diseases in which urinary bladder senses are not perceived. This kind of incontinence occurs in diseases such as multiple sclerosis, urinary bladder injuries urethral obstruction or diabetes causing damage in the nerves or spinal cord injuries.
Mixed incontinence: Sometimes incontinence develops not only as stress incontinence but also as urge incontinence and it is classified as mixed incontinence.
Total incontinence: It defines urinary incontinence at night and day time, continually or periodically.
When to consult a physician?
Complaints related to urinary incontinence should always be reported without hesitation when examined by a physician. Because it is not a condition which should be embarrassed about or a part of normal life. But in conditions stated below, physician should be consulted promptly:
*Severe urination problems in addition to urinary incontinence (noticing blood in urine, difficulty in urination)
*In cases when urinary incontinence affects your daily activities, social relations, life quality and daily plans
*You should consult to a physician promptly if urinary complaints progress in time.
Causes of the Urinary Incontinence
Urinary continence is not a disease but a symptom, a finding. It may be caused by any medical or psychological situation of your daily life. Urinary incontinence may be permanent or temporary.
Conditions which may cause temporary Urinary Incontinence
*Alcohol
Since alcohol enhances urine production and stimulates urinary bladder , alcohol may cause urinary incontinence.
*Excessive fluid intake
Excessive fluid intake in short time may cause incontinence due to increase in urine production.
*Caffeine
By increasing the urine production and stimulating the urinary bladder, it may cause incontinence. Over consumption of drinks such as tea, coffee and energy drinks may be the reason for incontinence.
*Urinary Bladder Stimulants
Fizzy drinks, tea and coffee (those which include caffeine or not), sweeteners, corn syrup, spicy foods and drinks, sweet and acidic foods, fruits and vegetables such as lemon and tomato may cause temporary incontinence by stimulating urinary bladder.
*Medications
Usage of cardiac medications, hypertension medications, ataractics, myorelaxants may cause urinary incontinence.
*Urinary Tract Infections
Infections directly stimulate urinary bladder and especially cause urge incontinence. In addition to urinary incontinence, burning and bad smell with dark colored of urine discharge may develop during urination. İncontinence recovers with proper infection treatment.
*Constipation
Rectum and urinary bladder are the organs which are in close adjacency and controlled by similar nerves. Frequency in urination or hyperactive urinary bladder syndrome may develop in situations of compact solid stool or constipation, sometimes it may cause overflow type urinary incontinence.
Conditions which may cause permanent urinary Incontinence
*Pregnancy and Delivery
İncontinence may develop due to rapid gaining of weight, hormonal changes, enlargement of cervix and its compression towards urinary bladder. Additionally, permanent incontinence may develop as a result of weakness and injuries in pelvic muscles due to compression over pelvic muscles . Pelvic and vaginal prolapses may develop due to damage occurred in pelvic muscles, nerves and supportive tissues during delivery. In vaginal prolapse, urinary bladder, cervix, rectum and sometimes small bowels may bulge come out of the vagina and this type of prolapses may cause urinary incontinence.
*Changes related to age
Storage capacity of the urinary bladder reduces as person gets older and hyperactive urinary bladder symptoms progress. These complaints are more prominent in elder women especially having systemic disease. Hyperactive urinary bladder complaints related to age may be reduced or avoided by giving up smoking, an active life style, exercising, controlling the diseases such as hypertension and diabetes with proper treatment. Tendency for urinary incontinence increases since bleeding and feeding of the urethra reduce due to estrogen hormone which is reduced during menopause. But interestingly, estrogen treatments in postmenopausal period may exacerbate urinary incontinence.
*Hysterectomy (surgical removal of the cervix)
Cervix and urinary bladder are in close adjacency with the muscles and fibers supporting the cervix also support the urinary bladder. Surgical removal of cervix may cause weakening of the supportive tissues of urinary bladder and urinary continence may develop as a result of weakening in pelvic muscles.
*Painful Urinary Bladder Syndrome (interstitial cystitis)
It is a syndrome characterized with chronic painful and frequent urination whose cause is not clearly known and it may cause incontinence for sometimes.
*Urinary bladder Cancer and Urinary Tract Calculi
Incontinence, immediate sense of urination, burning during urination may be the symptoms of urinary tract calculi and urinary bladder cancers. It may also cause blood in urine and pelvic pain.
*Neurologic Diseases
Multiple sclerosis, Parkinson disease, stroke, brain tumors, spinal cord injuries may cause defect in nerve conduction of urinary bladder and as a result, urinary incontinence may develop.
*Obstruction and Compression
Tumors and masses originating from different organs within the abdomen and causing compression through urinary tract (from kidneys till urethra) may cause overflow incontinence. Calculi in the kidney, urinary bladder and urinary tract may cause overflow incontinence with similar mechanism.
Risk Factors
*Gender
Not only because of anatomic characteristics but also because of pregnancy, delivery and menopause, urinary incontinence is more common in females.
*Age
As one gets older, frequency of incontinence increases due to weakness in urinary bladder muscular structure and pelvic floor muscular structure. But, incontinence is not accepted as normal as a natural process of getting old, it may be treated and life quality can be increased.
*Obesity
İncontinence may develop as a result of increase in pressure over urinary bladder and pelvic floor muscles due to excessive gaining of weight. Stress incontinence is common with coughing and sneezing as a result of weakened pelvic muscles.
*Smoking
Chronic coughing and continually increased intra-abdominal pressure which develop due to smoking increases especially the risk of stress incontinence. Smoking also affects contraction of urinary bladder and may cause overflow incontinence
*Systemic Diseases
Systemic diseases such as renal diseases and diabetes increases the risk of continence.
Complications
*Skin problems
Urinary incontinence cause continuous exposure of urine in genital region skin and skin Rashes, redness, ulcers (wounds) may develop on genital region skin .
*Urinary Tract Infections
İncontinence causes repeating urinary tract infections.
*Changes in daily life
As a result of incontinence limits the daily activities of the person by limiting sports and exercise activities and giving the idea of accessing to the toilet in places in daily routine.
*Changes in business life
Urinary incontinence has a negative effect in business life. It avoids person’s attendance in longer meetings and may cause problem in concentrating due to stress and discomfort able feelings. It may also cause fatigue and weakness due to disturbed sleeping at nights.
*Changes in life quality
It has a negative effect in life quality. Self-confidence reduces, person avoids sexual intercourse with a fear of urinary incontinence during sexual activity. Diseases such as anxiety and depression are also very common in females having incontinence problem.
Diagnosis and Tests
Most significant factor in diagnosing urinary continence is patient’s medical history. Type and severity of incontinence can be diagnosed by questioning the medical history of the patient considering when it started, how severe and frequent it is and how it affects life quality.
There is a group of specific and non-specific tests which may help while diagnosing other than the medical history:
*Urinary bladder diary
It is a form including the daily fluid intake, frequency and amount of urination. The record is kept for 1 week and patient’s urination profile and level of incontinence are determined.
*Urine Analysis
Urinary analysis reveals urinary tract infections, findings belonging to blood or calculus in urine.
*Blood Tests
Beside not being beneficial for direct diagnosis of incontinence, it may be beneficial for examining the systemic diseases such as diabetes which may cause incontinence
*Postvoid residual measurement
It’s a procedure which measures the residual urine in urinary bladder after the person urinates via a thin catheter or ultrasonography. Excess amount of urine in urinary bladder after urination shows presence of problem in nerve or muscular layer of urinary bladder and obstruction or problem in urinary tract.
*Pelvic USG
Urinary bladder capacity and anomalies of urinary bladder, kidneys and urinary tract, tumors, calculi and obstructions can be detected via USG.
*Stress Test
It is a simple but a significant test depending on observing whether incontinence is present by causing increase in intra-abdominal pressure as a result of coughing or straining during gynecologic examination.
*Urodynamic tests
These tests are based on measurement of pressure during resting and voiding of urinary bladder. These tests require inserting catheter to urethra and urinary bladder and special pressure gauge devices. Beside not being always necessary for the diagnosis of incontinence, it may be helpful for treatment alternatives especially in patients in whom type of the incontinence is not definite.
*Cystogram
Problems in urinary tract can be diagnosed by obtaining serial X ray films following to administration of contrast agent to the urinary bladder.
*Cystoscopy
It is a technique for monitoring the urinary bladder and urinary tract directly via a thin cannula including camera system by entering from urethra. It is able to be performed not only in office environment, it can be easily performed also under general anesthesia or spinal anesthesia in operating room.
Treatment of urinary Incontinence
Treatment of urinary incontinence is related to type and severity of incontinence. There is a variety of medical and surgical treatments and these treatments may be personal according to the case. In most patients, physical and behavioral therapies are preferred initially. In next stages, surgery and combined treatments are preferred in patients having severe anatomic problem or in severe urinary incontinence cases.
Behavioral Techniques
Behavioral techniques and changes in life style are mostly beneficial in incontinence treatment and additional treatment is not required in many cases.
Urinary Bladder Exercises; Urinary bladder exercises consist of the technique of training the urinary bladder by delaying the urination and holding the urine for a certain time when sensation of urination comes. It is initiated when sensation of urination comes by delaying the urination for 10 minutes. The target here is being able to prolong the intervals of going to the toilet up to 2-4 hours. Urinary bladder exercise also includes discontinuing it during urination, holding it for a while and re-urinating.
Planned Toilet Exercises; define planned urination. Urinary bladder training is done by planning to go to the toilet once every 2 to 4 hours.
Fluid intake and diet; Reducing the consumption of alcohol, acidic fluid and foods, fluids with caffeine reduce the severity of incontinence. In some patients, incontinence problem may be recovered by reducing fluid consumption, losing weight, physical exercise and changes in life style.
Physical treatment:
Exercises for Pelvic Floor Muscles
Special exercises which include pelvic floor muscles and urinary bladder valves are helpful for urine control. Continence can be achieved with treatments done in periodic sessions with guidance of physical therapy . Exercises of pelvic floor muscles “Kegel Exercises” are based on repeatedly voluntary contracting and relaxing the muscles that form part of the pelvic floor. During urination, voiding is discontinued by contracting the pelvic muscles and voiding is continued after counting until three; this is then repeated periodically. It is important to work the proper muscles, not working the abdominal and leg muscles enables working the pelvic floor muscles correctly. In order to perform kegel exercises effectively, it should be performed initially with guidance of physician and physiotherapist and after the patient learns how to work correct muscle group, self treatment should be continued personally.
Electrical Stimulation
This is a treatment modality based on inserting electrodes to the pelvic floor muscles around vagina and rectum and their contraction with the electrical stimulation. Being an effective treatment method for stress and urge incontinence, many numbers of Electrical stimulation sessions are required and the treatment should be continued for months.
Pharmacologic Treatment
Pharmacologic medication treatments are mostly used by combining it with behavioral and physical treatments. Medication alternatives vary from patient to patient and sometimes they can be used in combination. Usage of medication should be chosen by the physician and continued under the supervision of the physician. All medications may have serious side effects. Main medications groups are:
* Anticholinergics,
This group of medications are mostly used in urge incontinence treatment, hyperactive urinary bladder syndrome and mixed type incontinence. Medications within this category are oxybutynin, tolterodine, darifenacin, fesoterodine,trospium and solifenac. Side effects of these medications are dry-mouth, constipation, blurred vision and hot flushes. Beside being limited, local crèmes and tablets with estrogen, locally administered estrogen vaginal creams and tablets may be effective in incontinence by enhancing cell repair and feeding the tissues in urinary tract.
* Imipramin
Imipramin is an adtideppressant and used in stress, urge and urinary incontinence as well as enuresis nocturna (urnary incontinence of children at night time).
*Duloxetin;
is a new generation antidepressant and used in stress incontinence treatment for selected patients.
Medical Devices
Although their place in treatment of incontinence is limited , many medical tools and devices are used. Urethral inserts like mini tampons may prevent incontinence by blocking urethral outlet but their usage more than 24 hours is inconvenient. Urethral inserts may be used in heavy activities but their routine usage is very limited. But vaginal ring shaped silicon pessaries can be used in patients especially having vaginal prolapse. Pessaries can be used effectively after sufficient training supplied for the patients who are inoperable and prolapse. By inserting the pessary to the vagina, it not only supports pelvic floor muscles but also contributes treatment of incontinence by elevating urinary bladder. Since long term usage of pessary may cause ulcers and infection in vagina, it is necessary to discontinue using it periodically.
Surgical Procedures and Operations
*Injections of synthetic material
Several synthetic materials such as Carbon-coated zirconium, calcium hydroxyapatite, polydimethylsiloxane are injected to the urethra inferiorly and peripherally. It avoids incontinence by supporting the supportive tissue below the urethra and urinary neck. It is a very simple technique and despite being applied in 5 minutes under local anesthesia in office environment, the intervention should be repeated periodically. Success rates are around 60%.
* Botulinum toxin type A
Botox application to the muscular later of the urinary bladder is beneficial especially in hyperactive urinary bladder syndrome and urge incontinence types. But if Botox application is performed more than normal amounts, the patient may have difficulty in urinating. It is recommended to be repeated once in 6 to 9 months.
*Nerve stimulator devices
Devices stimulating sacral nerve responsible in urinary bladder nerve stimulations and nerve stimulator applicable to the leg hip are available but their usages are very limited.
Surgical treatment
Today, surgical treatment is the most common and effective treatment thanks to the development of surgical techniques and synthetic mesh technology. But selection of patient and appropriate treatment is highly important. The surgery can be performed laparoscopically, vaginally or through the abdomen. Today, the most effective method are vaginal surgical techniques. The patient can be discharged from the hospital 1 day later and return to daily life immediately. Most common surgical procedures are Sling operations. These operations are based on forming pelvic strap by using synthetic or biomaterial and supporting he urinary bladder neck and urethra. TVT, TOT and mini-sling techniques are popular operations. These may be performed approximately in 15 minutes under general or spinal anesthesia . Patient is able to be discharged from the hospital next day. Success rates are above 90%. These are the most common gynecologic operations in the world. Complication rates are very low. Results in mixed type incontinence and stress incontinence which is the most common incontinence type and this effects to the patient’s life quality are curative.
Laparoscopically, BURCH operations also have the equal success rates same as vaginal surgeries. These are safly performed in appropriate patient. Open abdominal surgery is performed very rarely for incontinence.
Alternative treatments
Today, there is no proven alternative treatment modality for urinary incontinence. Although there are studies related to hipnotherapy, magnetic stimulation, reflexology and acupuncture applications, their efficiency have not been presented.
Protection and Prevention of Urinary Incontinence Urinary incontinence is not a disease which can be prevented anytime but the risk can be reduced with some life style modalities. Recommendations for reducing urinary incontinence risk:
- Healthy weight control
- Avoiding obesity and maintaining the ideal weight reduce the incontinence risk.
- Smoking
- Not smoking and giving up smoking reduce incontinence risk
- Kegel Exercises, Performing Kegel Exercises in daily life especially during pregnancy reduces the incontinence risk.
- Avoiding urinary bladder stimulators. Limiting the consumption of the foods and drinks which have urinary bladder stimulating effect reduces incontinence risk. For example, reducing the consumption of coffee and drinks with caffeine is recommended.
- Consumption of fiber foods, Diet rich in fiber foods and avoiding constipation reduce the development of incontinence risk.
- Exercise and regular sports,Regular physical activity reduce the development of incontinence risk.
Urinary incontinence is an important health problem affecting 30-40% of females especially above 30’s. As a result of being so common in the community, it is almost percepted as a part of normal life . Women try to struggle with this problem by using absorbent peds, carrying extra underwear or by reducing fluid intake and consulting to a physician is not sufficient not only because it is percepted as part of normal life but also because of embarrassment. Thus, females with urinary incontinence perform their daily activities and plan their social life considering this problem and limit their life quality seriously. Psychological problems such as sexual problems, self confidence, anxiety and depression are also very common in females with incontinence. But thanks to development of modern medicine and surgical techniques, incontinence problem in females is successfully treated in today’s world. Studies show that there is significant increase in social life and life quality, self confidence and sexual life of the females after the treatment. As a result, urinary incontinence in females is not a part of normal life but a disease which can be treated.